Official Federal Forms > Centers For Medicare And Medicaid Services
Detailed Explanation Of Non-Coverage CMS-10095 - Official Federal Forms
| Detailed Explanation Of Non-Coverage Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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OMB Approval No. 0938-0910 Insert Logo here DETAILED EXPLANATION OF NON-COVERAGE Date: Patient Name: Patient ID Number: This notice gives a detailed explanation of why your MA plan and/or provider has determined that Medicare coverage for your current {insert type} services should end. This notice is not the decision on your appeal. The decision on your appeal will come from your Quality Improvement Organization (QIO). We have reviewed your case and decided that Medicare coverage of your current {insert type} services should end. · The facts used to make this decision: · Detailed explanation of why your current services are no longer covered under your MA plan, and the specific Medicare coverage rules and policy used to make this decision: · {Insert MA plan} policy, provision, or rationale used in making the decision: If you would like a copy of the policy or coverage guidelines used to make this decision, or a copy of the documents sent to the QIO, please call us at {insert MA plan or provider telephone number}: Form No. CMS-10095 Exp. Date 03/31/2007 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to distribute this information collection is 60 - 90 minutes per notice, including the time to select the preprinted form, gather the needed information, complete the form, and deliver it to the enrollee. If you have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. American LegalNet, Inc. www.USCourtForms.com
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